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Since its introduction nearly 30 years ago, sentinel lymph node biopsy (SLNB) has become the standard technique to stage the axilla for the great majority of patients with early breast cancer. While the accuracy of SLNB in clinically node-negative patients who undergo neoadjuvant chemotherapy (NAC) is similar to the upfront surgery setting, modifications of the technique to improve the false negative rate are necessary in node-positive patients at presentation. Currently, patients who present with matted nodes, cN1 patients who fail to downstage to cN0 with NAC and those with pathological residual disease have an indication to undergo axillary lymph node dissection. Ongoing trials will confirm if extensive nodal irradiation can replace surgery in patients with residual nodal disease after NAC and if nodal radiotherapy can be omitted in patients who achieve nodal pathological complete response. The aim of this review was to focus on the open questions on the management of the axilla after NAC.

Advances in reconstructive breast surgery with new materials and techniques now allow us to offer patients the best possible cosmetic results without the risks associated with oncological control of the disease. These advances, in both oncological and plastic surgery, have led to a new field, oncoplastic breast surgery, which enables us to undertake large resections and, with advance planning, and prevent subsequent deformities. This is particularly important when more than 30% of the breast volume is removed, as it allows us to obtain precise information for conservative surgery according to the site of the lesion and to set the boundary between conservative surgery and mastectomy.

Augmented reality (AR) enables the superimposition of virtual reality reconstructions onto clinical images of a real patient, in real time. This allows visualization of internal structures through overlying tissues, thereby providing a virtual transparency vision of surgical anatomy. AR has been applied to neurosurgery, which utilizes a relatively fixed space, frames, and bony references; the application of AR facilitates the relationship between virtual and real data. Augmented breast imaging (ABI) is described. Breast MRI studies for breast implant patients with seroma were performed using a Siemens 3T system with a body coil and a four-channel bilateral phased-array breast coil as the transmitter and receiver, respectively. Gadolinium was injected as a contrast agent (0.1 mmol/kg at 2 mL/s) using a programmable power injector. Dicom formatted images data from 10 MRI cases of breast implant seroma and 10 MRI cases with T1-2 N0 M0 breast cancer, were imported and transformed into augmented reality images. ABI demonstrated stereoscopic depth perception, focal point convergence, 3D cursor use, and joystick fly-through. ABI can improve clinical outcomes, providing an enhanced view of the structures to work on. It should be further studied to determine its utility in clinical practice.

Indications for post mastectomy radiotherapy are widening to a larger group of mastectomy patients and breast reconstruction rates following mastectomy are rising all over the world, this leading breast surgeons to face breast reconstruction in a growing number of patients who will undergo radiotherapy. Increased morbidity is associated with all forms of breast reconstruction in the setting of postmastectomy radiotherapy and in patients who previously underwent chest wall radiotherapy. Different attitudes towards breast reconstruction in the radiotherapy setting are presented in literature. The level of evidence and quality of studies investigating breast reconstruction in the setting of PMRT and in patients who previously underwent chest wall radiotherapy are low. The reconstructive option in the radiotherapy setting must be tailored on the single patient according with patients' characteristics and wishes, always considering that the best reconstructive timing must be driven by the best oncological timing.

Ductal carcinoma in situ (DCIS) has been the subject of much controversy since the advent of population based breast screening programs. An increasing number of asymptomatic women are being diagnosed with this condition and there is uncertainty over the best treatment algorithm for this condition if treatment is to be considered at all. Different subtypes of DCIS show innate differences in developmental pathways and biological behavior. This is not only determined by pathological subtypes but there is increasing understanding of molecular biomarkers related to DCIS progression. The ultimate management aim is to identify a subgroup of patients in whom DCIS will not progress to invasive disease such that they can avoid morbidity from surgical and adjuvant therapies. This has to be balanced by the potential risk of undertreatment of patients in whom DCIS is likely to progress to invasive cancer and hence a reduced life expectancy. Results of current ongoing prospective randomized trials assessing the safety of omitting surgery for what is considered to be low risk DCIS are eagerly awaited for by patients and clinicians. However the definition of what is considered to be "low risk" DCIS is still to be ascertained.

We present a new reconstructive system encompassing prostheses and fat grafting as integrated tools to improve the final reconstructive outcome. Fat grafting in our view is a preoperatively planned part of the reconstruction. The final volume we achieve will be made up of fat and implants in a variable percentage according to patient's body contour and breast morphology. We used the hybrid breast reconstruction technique in more than 350 reconstructions, both immediate and delayed, two-stage and DTI, without experiencing higher loco-regional recurrence and complication rates when compared with conventional two-stage reconstructions, obtaining excellent aesthetic results and high patients' satisfaction levels.

Axillary surgery in breast cancer patients has shifted from more extensive to minimalist approaches with re-evaluation of the risks versus benefits of available treatment options which are increasingly tailored to individual patient characteristics. A radical axillary node dissection is rarely indicated nowadays due to several factors including screening with detection of small node negative cancers, introduction of targeted node sampling, less reliance on information from nodal staging for adjuvant therapy decision making and evidence that non-surgical treatments such as systemic therapies (chemotherapy, hormonal therapy, biological therapy) together with radiotherapy can safely treat low burden axillary disease. Sentinel lymph node biopsy (SLNB) alone with omission of further axillary surgery for nodal macrometastases (>2 mm) might be sufficiently extirpative to achieve local control when combined with adjuvant treatments. There remain unanswered questions on the safety of SLNB post chemotherapy in patients with biopsy-proven nodal disease at presentation and whether omission of axillary node dissection is feasible in selected cases. Emerging evidence suggests that a complete radiological response with removal of at least 3 nodes (including clipped nodes at time of biopsy) can yield false negative rates of <10% and be a safe option. New technologies involving percutaneous biopsy of sentinel nodes under radiological guidance are under investigation and could potentially replace surgical staging of the axilla in the future. Moreover, omission of any type of node biopsy might be a potential option in more favorable tumors and could herald the beginning of the end for histological axillary sampling in selected cases.

Breast cancer is the most common form of cancer and second main cause of death in women in western countries. Breast-conserving therapy, consisting of lumpectomy and radiation therapy, has become the standard local treatment for T1-T2 breast tumors. There is general agreement that successful breast conservation requires complete tumor excision with a "tumor-free" or "negative" margin of resection, but the definition of a negative margin is controversial. A commonly accepted definition of adequate margins requires a 2-mm distance between ink and tumor but opinions range from the original National Surgical Adjuvant Breast and Bowel Project definition of "no ink on tumor", to a recommended width of 10 mm or more. The ability to perform real-time molecular imaging analysis of margins during surgery would clearly be a significant advance; several groups have engaged in this effort, with encouraging reports of preliminary data. Further development of such techniques promises to lead to a point at which accurate intraoperative margin evaluation may be possible and may even be combined with therapeutic interventions, using techniques such as photodynamic therapy.